Hydrops and Hydrops Diet

Timothy C. Hain, MD • Page last modified: March 6, 2021

A one-page version of the hydrops diet is found here

Normal membranous labyrinth

Dilated membranous labyrinth in Meniere's disease (Hydrops)

Hydrops means that the pressure in the inner ear is elevated. Dogma states that all persons with Meniere's disease have hydrops. Actually this is a bit implausible as one would imagine that one could meet the criteria for Meniere's disease rather simply by combining a preexisting hearing loss (say from an inner ear infection), with appropriate symptoms. Still, perhaps one could reasonably say that most persons with Meniere's have hydrops on autopsy. There is another group called "delayed endolymphatic hydrops". More about this is on the link. Another group may be autoimmune inner ear disease patients, as these have been reported on MRI imaging to have hydrops as well.

However, not all persons with hydrops have Meniere's disease, as this depends on meeting the committee's criteria. Generally what is missing is hearing loss.

Isolated hydrops

There are persons who have hydrops (documented with the ECochG test), who do not meet the diagnostic criteria for Meniere's disease. These people are simply diagnosed as having "hydrops". Another method of documenting hydrops is with MRI. See the link for more.

An example of an individual with "hydrops" is below. This patient had several ECOG tests done over many years, most of which showed enlarged SP/AP ratios (> 0.5). Hearing was always normal. Symptoms consist of mild and intermittent dizziness, associated with nystagmus (downbeating nystagmus upright, mild right-beating nystagmus, also burst of downbeating after head-shaking).

2010 hydrops 2015 ecog 2015 audio
ECOG from 2010 -- bilateral hydrops ECOG from 2015 -- bilateral hydrops Audiogram from 2015 -- normal hearing.

Comment: patients with hydrops alone do not fit the committee criteria for Meniere's disease, generally because they omit hearing loss. The author of this page treats them as if they had Meniere's disease (see algorithm). As MRI techniques improve for diagnosing hydrops, perhaps we will get confirmation that this is a real disorder.

An emerging method of diagnosing hydrops is to compare the caloric response (which is a low-frequency vestibular test) to the VHIT test, a high frequency test. According to Choi et al (2017), "abnormal caloric tests with normal vHIT in MD indicated severe endolymphatic hydrops rather than vestibular hypofunction". This is an example of the VHIT conflict problem. We are a bit dubious about this, but it warrants investigation.

According to Shi et al (2018), who studied Meniere's patients who had MRI scans for hydrops, "Low-frequency hearing loss was significantly correlated with the extent of both vestibular and cochlear hydrops, whereas the vertigo attack frequency showed no significant correlation with ELH grades. " This suggests that hydrops does not predict dizziness.

Hydrops Diet

The fluid-filled hearing and balance structures of the inner ear normally function independent of the body's overall fluid/blood system. In a normal inner ear, the fluid is maintained at a constant volume and contains specific concentrations of sodium, potassium, chloride and other electrolytes. This fluid bathes the sensory cells of the inner ear and allows them to function normally.

With injury or degeneration of the inner ear structures, independent control is lost, and the volume and concentration of the inner ear fluid fluctuates with changes in the body's fluid/blood. This fluctuation causes the symptoms of hydrops--pressure or fullness in the ears, tinnitus (ringing in the ears), hearing loss, dizziness and imbalance.

The core element to the hydrops diet for Meniere's is a reduced sodium input -- generally between 1500-2000 mg. Note that it is not the overall level of sodium that is important, but whether or not it fluctuates. To put this into perspective, the average daily intake of sodium for persons in the US is about 3400 mg, and dietary guidelines for everyone recommend reducing it to < 2300 mg/day in general, and 1500 mg for African American. Thus the hydrops diet is almost identical to the recommendations for a healthy diet for persons in general. (Medical letter, 2014)

Curiously, less than 1.6% of US adults consume less than 2300 mg/day of sodium. Thus a "low sodium" diet is not at all the same as a "regular" diet. (Rehm et al, 2016)

Furthemore, it is not necessary or wise to lower your salt intake to amounts barely able to sustain life. We do not encourage use of 1 gram sodium diets. Rather the goal is to keep sodium levels from fluctuation, and also on the low side of normal. A 1.5 or 2 gram sodium diet is usually possible. Note, we are not suggesting a 2 gram "salt" diet -- but rather a 2 gram "sodium" diet. Salt has both sodium and chloride. We are only trying to control the sodium part.

History of the hydrops diet:

An early version of the hydrops diet was proposed by Furstenberg (1934). He suggested that protein and calories need not be restricted, but that salt should be "low". Dr. Furstenberg provided an elaborate list of foods to be taken daily or avoided. He did not restrict caffeine at all, and did not mention sugar, alcohol, or nicotine. Dr. Furstenberg advocated use of "acid producing salts" such as Ammonium chloride. Thus it can be seen that the Furstenberg diet is not synonymous with the "hydrops" diet, and in fact, does not even set the amount of sodium.

How does what I eat affect my dizziness?

Your inner ear fluid is influenced by certain substances in your blood and other body fluids. For instance, when you eat foods that are high in salt or sugar, your blood level concentration of salt or sugar increases, and this, in turn, will affect the concentration of substances in your inner ear.

People with certain balance disorders must control the amount of salt and sugar that is added to food. You must also become aware of the hidden salts and sugars that foods contain. Limiting or eliminating your use of caffeine and alcohol will also help to reduce symptoms of dizziness and ringing in the ears.

Dietary goals

The goal of treatment is to provide stable body fluid/blood levels so that secondary fluctuations in the inner ear fluid can be avoided.

  1. Distribute your food and fluid intake evenly throughout the day and from day to day. Eat approximately the same amount of food at each meal and do not skip meals. If you eat snacks, have them at regular times.
  2. Avoid eating foods or fluids which have a high salt content. High salt intake results in fluctuations in the inner ear fluid pressure and may increase your symptoms. Aim for a diet high in fresh fruits, vegetables and whole grains, and low in canned, frozen or processed foods. A 2-gram sodium intake diet is usually what we recommend. One teaspoon of table salt has about 2 grams of sodium. Note that sodium (one of the two elements in table salt) is not exactly the same as sodium chloride (salt). A 2 gram "salt" diet is not what is intended. This web site: https://www.myfitnesspal.com, has a diet diary program that can be configured to track sodium.
  3. Drink adequate amounts of fluid daily. This should include water, milk and low-sugar fruit juices (for example, cranberry or cranapple). Try to anticipate fluid loss which will occur with exercise or heat, and replace these fluids before they are lost. Be cautious about the milk intake -- some individuals have food allergy and get symptoms from milk products.
  4. Avoid caffeine-containing fluids and foods (such as coffee, tea and chocolate). Caffeine has stimulant properties that may make your symptoms worse. Caffeine also may make tinnitus louder. Large amounts of caffeine may trigger migraine (migraine can be difficult diagnostically to separate from Meniere's disease). Chocolate is also a migraine trigger.
  5. Limit your alcohol intake to one glass of beer or wine each day. Alcohol may trigger migraine associated vertigo.
  6. Avoid foods containing MSG (monosodium glutamate). This is often present in pre-packaged food products and in Chinese food. It may increase symptoms in some patients, possibly because of the link to migraine associated vertigo, and also because it contains sodium.

Drug Considerations

  1. Avoid aspirin and medications that contain aspirin. Aspirin can cause tinnitus (abnormal noise in the ear). Nonsteroidal anti-inflammatory agents such as ibuprofen or naproxen should also be avoided when practical.
  2. Avoid caffeine-containing medications. Caffeine can increase tinnitus as well as have the problems mentioned above under foods.
  3. Pay attention to the content of all over-the-counter medications as well as drugs prescribed by other physicians. Some medications may increase your symptoms.

Where can I get additional help in modifying my diet?

Dietitians can help you work out a nutritional program which meets your special needs. They can also suggest ways to prepare your favorite foods for a restricted-salt or low-sugar diet. With their assistance, you'll find that modifying your eating habits can help you control the symptoms of your balance disorder.

Most grocery stores carry pamphlets that list the amounts of sodium in common foods.

"Apps" available on smartphones as well as websites on the internet can be of great help in tracking sodium. We do not advertise on this site, but nevertheless many of our patients have mentioned the "myfitnesspal.com" website as a useful resource. It seems likely that there are many other sites that do not have the annoying login requirement.

References: We have linked journal names that are from less reputable sources to our reference quality page.

Self-help groups.

Other Links

  • "https://www.menieres.org/:The Meniere's network
  • Review article: www.bmj.com/cgi/content/full/316/7128/368
  • Written By: Timothy C. Hain, MD of Chicago Dizziness and Hearing.